Provider Demographics
NPI:1992733463
Name:HUDSON, MARK A (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HUDSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 W IH 10
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-2700
Mailing Address - Country:US
Mailing Address - Phone:432-336-2004
Mailing Address - Fax:432-336-4545
Practice Address - Street 1:387 W IH 10
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735-2700
Practice Address - Country:US
Practice Address - Phone:432-336-2004
Practice Address - Fax:432-336-4545
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA 3160163W00000X
TX617497367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX773755OtherMEDICARE NUMBER